Accessible Marine Insurance

Insurance for the Marine Industry Worldwide

Certificate of Insurance Request

certificate_of_insurance

Use this certificate request form to issue a Certificate of Insurance ( COI ) evidencing your insurance coverage as required by your contract.  This form is for existing clients who are required to issue a COI to their customers.  Please contact our office if you have any questions completing this form.

Certificate of Insurance Request Form

  • Insert the company name of the entity who has purchased the policy.
  • Insert the company contact name of the entity who has purchased the policy.
  • Insert the company phone number of the entity who has purchased the policy.
  • Insert the company name of the entity requesting the certificate of insurance. This is not the company who purchased (owns) the policy.
  • Insert the company address of the entity requesting the certificate. This is not the company who purchased the policy.
  • Insert the company contact name of the entity requesting the certificate. This is not the company who purchased the policy.
  • Insert the company email address of the entity requesting the certificate. This is not the company who purchased (owns) the policy. The certificate of insurance will be emailed to this address.
  • Does your client who is requesting the certificate of insurance want to be listed as an Additional Insured to your policy?
  • This field is for validation purposes and should be left unchanged.

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